- A 40-year-old client is being discharged from an outpatient mental health program after treatment for depression related to divorce and job stress; medical history includes hypertension. The client denies current suicidal intent but reports intermittent thoughts of "not wanting to live" and appears anxious with poor concentration. The nurse reviews the client's written safety plan. The nurse should QUESTION which part of the safety plan?
Answer: "If I feel unsafe, I will drive to a secluded area so I can calm down alone."
This question tests suicide risk assessment and safety planning skills. The priority concern is ensuring the safety plan promotes protective behaviors rather than increasing isolation and risk. The statement about driving to a secluded area to calm down alone (Option A) should be questioned because isolation during crisis moments increases suicide risk rather than providing safety. Securing firearms with someone else holding the key (Option B), listing specific warning signs (Option C), and having a clear contact plan when coping skills aren't sufficient (Option D) are all appropriate safety plan components. The decision-making principle is that effective safety plans should connect individuals to support and resources, not promote isolation during vulnerable moments. A transferable strategy is to review safety plans for any elements that increase isolation or reduce access to help, ensuring all components move the person toward connection and support rather than away from it.
- A 45-year-old client is brought to the emergency department by a coworker after stating, "I'm done with everything." Psychosocial history includes recent bankruptcy and estrangement from adult children; medical history includes hypertension. The client appears agitated, smells of alcohol, and refuses to answer questions about self-harm. Which action should the nurse take FIRST to ensure client safety?
Answer: Place the client in a room near the nurses' station and initiate one-to-one observation per policy
This question tests suicide risk assessment and safety planning. The priority concern is the client's immediate safety due to agitation, alcohol odor, refusal to discuss self-harm, and a statement implying suicidal intent. Placing the client in a room near the nurses' station and initiating one-to-one observation per policy is the most effective action as it ensures constant monitoring and prevents self-harm opportunities. Asking for details about stressors, requesting sedative medication, or providing counseling information are less effective because they do not address the acute need for supervision in a potentially suicidal client. In suicide prevention, the principle is to maintain a safe environment through observation when risk is suspected but not verbalized. This protects the client until a full assessment can be completed. A transferable strategy is to implement suicide precautions immediately in non-communicative clients with warning signs, adjusting based on ongoing evaluation.
- During a home health visit, a 67-year-old client recently discharged after a suicide attempt by medication overdose is being followed for heart failure and chronic pain from osteoarthritis. The client lives alone since their spouse died 8 months ago and states, "I don't see the point," while appearing poorly groomed with slowed speech. Which action should the nurse take FIRST to ensure client safety?
Answer: Assess current suicidal thoughts, intent, plan, and access to medications, and do not leave the client alone if risk is present.
The client's recent suicide attempt, hopeless statement, social isolation, and slowed speech make immediate self-harm risk the highest priority. The correct action is to assess if suicidal thoughts, intent, plan, and access to means are present, and to stay with the client if risk exists. This is the only option that directly addresses the potentially lethal danger. Reviewing the low-sodium diet and daily weight log, and reinforcing the heart failure medication schedule, is useful chronic care but does not assess or stop a possible suicide attempt. Grief counseling and bereavement support are relevant to the spouse's death, but they cannot be the first step when acute risk may be present. Changing an antidepressant dose and scheduling a two-week follow-up is premature; medication decisions should be made after a suicide risk assessment, and two weeks is too long to wait for a client expressing hopelessness after a recent overdose. Complete the safety assessment first, and do not leave the client alone if risk is present.
- A 48-year-old client is on an inpatient psychiatric unit for major depressive disorder. Psychosocial history includes recent job loss; medical history includes chronic kidney disease. The client has been withdrawn but today appears calm, is smiling, and tells the nurse, "You won't have to worry about me much longer." Which finding requires IMMEDIATE intervention by the nurse?
Answer: Sudden mood improvement with a vague statement suggesting imminent self-harm
This question tests suicide risk assessment and safety planning. The priority concern is the client's immediate safety on an inpatient unit with depression and a sudden mood change paired with a vague threatening statement. The sudden mood improvement with a statement suggesting imminent self-harm requires immediate intervention as it may indicate a resolved decision to act. Improved appetite, calling family, or participating in therapy are positive but less urgent without risk signals. In suicide prevention, abrupt calm after depression can signal high risk, necessitating urgent reassessment. This prevents undetected attempts. A transferable strategy is to monitor for paradoxical mood shifts in depressed clients and intervene promptly.
- A 34-year-old client is in the emergency department for severe depression after a recent divorce and job loss. History includes alcohol use disorder in early remission and chronic back pain treated with opioid medication; the client appears tearful with flat affect and states, "Nothing matters anymore." What is the nurse's PRIORITY assessment when evaluating suicide risk?
Answer: Ask the client directly about suicidal thoughts, plan, intent, and access to lethal means
The priority is to determine whether the client is in immediate danger. Asking directly about current suicidal thoughts, a concrete plan, intent to act, and access to lethal means (such as prescribed opioids or alcohol) is the only option that directly evaluates imminent suicide risk and guides immediate safety measures. Assessing sleep and appetite is useful for gauging depression severity, but it does not reveal whether the client has thoughts or plans for suicide. Exploring childhood trauma and coping styles may identify contributing factors, but it is a broader history-taking task and should not precede direct screening when the client expresses hopelessness. Obtaining a urine toxicology screen can identify substances affecting mood and judgment, but it does not assess suicidal ideation, plan, or intent and is not the first priority unless acute intoxication or overdose is suspected. When a client with depression and access to lethal means states "Nothing matters anymore," direct, validated suicide screening is essential to identify imminent risk and allow protective interventions such as constant observation or hospitalization.
- A 41-year-old client is evaluated in the emergency department after a panic attack at work. Psychosocial history includes recent termination notice and heavy alcohol use on weekends; medical history includes gastroesophageal reflux disease. The client is visibly anxious and states, "Sometimes I think everyone would be better off if I wasn't here." Which action should the nurse take FIRST to ensure client safety?
Answer: Ask directly about current suicidal ideation, plan, intent, and access to lethal means
The client's statement that others would be better off if the client were not here suggests possible suicidal ideation, especially in the context of recent job loss and heavy alcohol use. The nurse's priority is to determine immediate risk. Asking directly about current suicidal ideation, plan, intent, and access to lethal means is the only option that directly assesses the danger and guides next steps. Requesting an anti-anxiety medication addresses panic symptoms but bypasses the safety assessment and could delay intervention. Discussing employee assistance program resources and financial counseling addresses the job loss but not the suicidal statement, so it is not the first action. Teaching grounding techniques can help manage anxiety but does not evaluate or respond to the risk of self-harm. Because the client's safety is the priority, the nurse must ask the suicide-specific questions before considering symptom management, resource referral, or coping strategies.
- In an urgent care clinic, a 28-year-old client with a history of depression and recent initiation of a selective serotonin reuptake inhibitor 10 days ago presents with agitation and insomnia. The client is pacing, has rapid speech, and reports a recent eviction notice and increased alcohol use; they state, "I keep thinking about crashing my car into a bridge." Which finding requires IMMEDIATE intervention by the nurse?
Answer: The client describes a specific method for suicide involving their car and indicates they drove themselves to the clinic
This question tests suicide risk assessment and safety planning skills. The priority concern is immediate client safety as the client has expressed a specific suicide plan involving their car and has current access to this lethal means. The client describing a specific method involving their car and indicating they drove to the clinic (Option C) requires immediate intervention because it demonstrates high lethality risk with immediate access to means. Alcohol use affecting sleep (Option A) and psychomotor agitation (Option B) are concerning but don't indicate immediate danger; stopping caffeine (Option D) is actually a positive coping strategy. The decision-making principle is that specific suicide plans with immediate access to lethal means represent the highest risk and require immediate protective action. A transferable strategy is to assess not only for suicide plans but also current access to means - when both are present, immediate intervention such as removing access to the means or hospitalization is necessary.
- A 70-year-old client is seen in a community clinic after the death of a longtime partner. Medical history includes chronic obstructive pulmonary disease and chronic pain; psychosocial history includes limited family contact. The client has a depressed mood, slowed speech, and states, "I've been saving my pills." What is the nurse's PRIORITY assessment when evaluating suicide risk?
Answer: Ask how many pills have been saved, whether the client has a plan to use them, and when the client intends to act
This question tests suicide risk assessment and safety planning. The priority concern is the client's immediate safety given depression, isolation, and the statement about saving pills, suggesting potential overdose intent. Asking how many pills have been saved, if there is a plan, and when the client intends to act is the most effective as it quantifies risk and urgency. Assessing grief, oxygen use, or nutrition are less effective, focusing on secondary issues without addressing the implied suicidal plan. In suicide prevention, detailed inquiry into means and timing is essential for high-risk clients. This guides immediate protective actions. A transferable strategy is to probe specifics of hoarding behaviors in older adults with chronic illness and loss.
- A 38-year-old client is discharged from inpatient psychiatry after a suicide attempt by overdose 1 week ago and is now seen by a home health nurse. History includes depression and chronic insomnia; current mental status shows guarded behavior and minimal speech, and the client reports ongoing financial stress and access to leftover medications. Which action should the nurse take FIRST to ensure client safety during the home visit?
Answer: Assess current suicidal thoughts and collaborate to secure or remove all medications and other lethal means from the home.
After a suicide attempt by overdose one week ago, the immediate danger in the home is that the client may still be thinking about self-harm and still has leftover medications available. The option that directly addresses both risks is to assess current suicidal thoughts and collaborate to secure or remove all medications and other lethal means from the home. This combines suicide risk assessment with means restriction, the two most likely to prevent another attempt during the visit. Journaling may help the client identify negative thought patterns later, but it does not assess current suicidal intent or make the environment safer, so it cannot be the first action. Deep breathing, sleep hygiene strategies, and a bedtime routine may improve chronic insomnia, but they do not address the post-overdose risk or access to leftover medications; sleep hygiene can wait until immediate risk is addressed. The follow-up schedule, transportation plan, and medication list support continuity, but they do not identify current suicidal thoughts or stop access to lethal means in the home, so they are not the first safety action.
- A 62-year-old client is admitted to a medical-surgical unit for gastrointestinal bleeding. Psychosocial history includes recent diagnosis of cirrhosis related to alcohol use and estrangement from family; the client is withdrawn and states, "I don't want to wake up." Which action should the nurse take FIRST to ensure client safety?
Answer: Initiate suicide precautions per facility policy and assess for suicidal ideation, plan, intent, and access to means in the hospital
The correct first action is to initiate suicide precautions and assess for suicidal ideation, plan, intent, and access to means in the hospital. The statement "I don't want to wake up" is a possible expression of suicidal ideation, and immediate safety takes priority. Encouraging the client to talk with estranged family members by phone cannot provide the observation and environmental controls that prevent imminent self-harm; it may be a later step, not the first. Education about cirrhosis management and alcohol cessation resources is useful for the chronic illness but does not address the current suicide risk or place the client under any safety protocol. Requesting a psychiatric consultation and antidepressant medication may eventually be appropriate, but consultation and medication will not protect the client while waiting. The correct action is the only one that starts an immediate safety protocol and directly evaluates the client's suicidal ideation, plan, intent, and access to means in the current setting.
- An 18-year-old client is in an outpatient clinic after being suspended from school for fighting. Psychosocial history includes family conflict and recent breakup; medical history includes attention-deficit/hyperactivity disorder treated in childhood. The client appears angry, has pressured speech, and states, "I'm going to make them sorry—maybe I'll just end it all." What is the nurse's PRIORITY assessment when evaluating suicide risk?
Answer: Assess the client's access to weapons or other lethal means and whether there is a specific plan or intent to self-harm.
The priority in suicide risk assessment is to determine whether the client has a specific plan and the means to carry it out. The client's statement "end it all" and angry, pressured presentation make immediate safety the chief concern, so the nurse must first ask about access to weapons or other lethal means and about any concrete plan or intent to self-harm. The other options, while they address background factors, do not directly evaluate imminent danger. Dietary intake and caffeine use may be relevant to physical health but not to lethality. Academic performance and tutoring support relate to school functioning, not to self-harm risk. ADHD history and medication status are informative for treatment but do not address the client's current stated threat. Therefore, assessing access to lethal means and plan/intent is the correct first step.
- A 27-year-old client in an outpatient clinic discloses suicidal ideation after losing housing and separating from a partner. History includes major depressive disorder and one prior suicide attempt 3 years ago; the client is anxious, tearful, and reports access to a friend's handgun. The nurse and client begin developing a safety plan. The nurse should QUESTION which part of the client's safety plan?
Answer: "If I feel worse, I will drink alcohol to calm down before deciding what to do."
This question tests suicide risk assessment and safety planning. The priority concern is the client's immediate safety given suicidal ideation, access to a handgun, and history of a prior attempt. The nurse should question the plan to drink alcohol if feeling worse because alcohol can impair judgment, increase impulsivity, and heighten suicide risk, making it an unsafe coping strategy. Calling a support person, going to the emergency department or calling 988, or locking up the handgun are appropriate as they promote safety through support and means restriction. In suicide prevention, safety plans must avoid strategies that could exacerbate risk, such as substance use. Instead, they should include healthy coping, support contacts, and professional help. A transferable strategy is to collaborate with clients to identify and revise unsafe elements in safety plans, ensuring they reduce rather than increase risk.
- On an inpatient medical-surgical unit, a 45-year-old client admitted for pancreatitis related to alcohol use has a history of depression and a prior suicide attempt 5 years ago. The client appears withdrawn, speaks slowly, and says, "I can't do this anymore," and adds that they have been "thinking about ending it" since losing housing last week. Which action should the nurse take FIRST to ensure client safety?
Answer: Initiate continuous observation per facility protocol and remain with the client while ensuring the environment is free of potential weapons
The client's statement about "thinking about ending it" is active suicidal ideation, so the first priority is immediate physical safety. Initiating continuous observation, remaining with the client, and removing potential weapons provides direct protection while further evaluation is arranged. Notifying the provider and requesting a psychiatric consult is necessary, but it only arranges future evaluation; it does not safeguard the client during the waiting period. Encouraging a call to a family member may be supportive, but conversation alone cannot ensure safety, especially when the client is withdrawn and at imminent risk. Administering pain medication and reassessing mood addresses physical comfort but does not manage the suicidal crisis; the client remains unsupervised and at risk. The safest first action is continuous observation and environmental safety.
- A 22-year-old client in a university health clinic discloses suicidal ideation after a sexual assault 2 months ago. History includes depression; the client is tearful, hypervigilant, and reports keeping a bottle of prescription pain pills "just in case." The nurse assists with a safety plan. The nurse should QUESTION which part of the safety plan?
Answer: "I will keep the pills in my room so I can control them and not bother anyone."
This question tests suicide risk assessment and safety planning. The priority concern is the client's immediate safety with suicidal ideation, access to pills, and trauma history increasing vulnerability. The nurse should question keeping pills in the room for control as it maintains access to lethal means, heightening risk of impulsive acts. Identifying warning signs, contacting crisis lines, or locking up medications are appropriate for promoting safety and support. In suicide prevention, safety plans must emphasize means restriction to reduce opportunity for harm. Avoiding self-management of lethal items is key. A transferable strategy is to ensure safety plans include third-party involvement in securing means, especially post-trauma.
- A 57-year-old client is hospitalized on a telemetry unit after a myocardial infarction. Psychosocial history includes living alone and recent retirement; the client is tearful, expresses hopelessness, and states, "I don't see a reason to keep going." Which finding requires IMMEDIATE intervention by the nurse?
Answer: States, "I plan to stop all my heart medicines when I get home so it will be over."
In a client with hopelessness and a stated wish to stop going on, the most urgent finding is any specific, actionable self-harm plan. Saying that the client plans to stop all heart medicines at home so "it will be over" is a concrete lethal plan and requires immediate safety intervention. Worry about returning to previous activities and asking about cardiac rehabilitation is future-focused and does not reveal intent for self-harm. Requesting a chaplain and help making sense of what happened is an appropriate coping effort, not an imminent plan. Low energy, poor appetite, and difficulty sleeping are depressive symptoms that need follow-up but are not the immediate emergency. The nurse should prioritize the stated plan to end life.
- A 26-year-old postpartum client is seen in an obstetric clinic 4 weeks after delivery. Psychosocial history includes limited support and recent move; medical history includes anemia. The client appears tearful, reports feeling worthless, and states, "My baby would be better off without me." Which action should the nurse take FIRST to ensure client safety?
Answer: Screen for suicidal thoughts, plan, intent, and ability to keep self and baby safe, and do not leave the client alone if risk is present.
The client's statement, "My baby would be better off without me," is a red flag for possible self-harm or harm to her baby. To ensure safety, the nurse must first screen for suicidal thoughts, a plan, intent, and the ability to keep herself and her baby safe, and must not leave the client alone if risk is present. The education-and-reassurance option treats the client's feelings as normal and skips this immediate assessment. Requesting an antidepressant medication might be part of later treatment, but it does not address the current risk of suicide or harm to the baby. Teaching infant sleep and feeding routines can be useful, but it does not directly consider the range of the client's statement. Because the priority is safety, the correct first action is direct screening that includes both the client and infant.
- A 16-year-old client is in the pediatric clinic with a parent for headaches and stomachaches. Psychosocial history includes bullying at school and recent social withdrawal; medical history is unremarkable. The client is quiet, has a depressed affect, and the parent reports finding online searches about "painless ways to die." Which finding requires IMMEDIATE intervention by the nurse?
Answer: States, "I've been giving away my favorite things because I won't need them."
The client's statement about giving away favorite things because they won't be needed is the finding that requires the nurse to act immediately. Giving away possessions is a preparatory suicide behavior: the client is settling things rather than expecting a future. In the context of bullying, withdrawal, depressed affect, and online searches about painless death, this is a high-safety risk and should trigger immediate suicide assessment, supervision, and safety planning. The other findings are less urgent. Headaches that worsen on school days and do not improve with rest are somatic symptoms consistent with school-related stress; they warrant assessment but do not signal a suicide plan. Losing interest in hobbies and spending afternoons alone reflect anhedonia and social withdrawal—important risk factors, but not preparatory behavior like giving away belongings. Missing several school days because of stomachaches and fatigue is also a somatic/avoidant pattern; it is relevant but lacks the immediate threat shown by the giving-away statement. The three distractors are concerning risk factors; only the giving-away statement indicates possible imminent danger.
- A 33-year-old client is brought to a mental health urgent care by a sibling who is concerned about safety. Psychosocial history includes recent custody dispute and unemployment; medical history includes migraines. The client's affect is flat and the client states, "I wrote letters to my kids last night." Which action should the nurse take FIRST to ensure client safety?
Answer: Assess for suicidal plan, intent, and access to means and initiate constant observation if risk is high
A flat affect, recent losses, and writing letters to one's children are concerning cues because letter-writing can be a preparatory behavior for suicide. The first action must determine immediate risk: ask the client directly about suicidal plan, intent, and access to means, and begin constant observation if that risk appears high. This is the only option that combines assessment of imminent danger with a protective measure. Requesting an order for antidepressant therapy today may become part of treatment, but medication neither reveals whether the client has a plan or means nor provides immediate supervision, and a follow-up visit tomorrow is too late for an urgent safety question. Providing information about parenting support groups and legal aid, and arranging counseling later, responds to stressors but leaves the client unassessed and unsupervised now. Asking the sibling to monitor at home and call if symptoms worsen delegates the safety assessment to a layperson and gives no constant observation, so the client remains at risk. The nurse must first evaluate the suicide risk directly and act on it.
- In an emergency department, a 22-year-old client reports 2 weeks of depressed mood after a breakup and job loss. History includes major depressive disorder and alcohol use on weekends; medical history includes asthma. The client is tearful, has a flat affect, and states, "Nothing matters anymore—everyone would be better off without me." What is the nurse's PRIORITY assessment when evaluating suicide risk?
Answer: Ask the client if they have thoughts of suicide, a specific plan, access to lethal means, and intent to act
The client's statement "everyone would be better off without me" is a possible expression of suicidal ideation, so immediate safety is the priority. The nurse must ask directly about thoughts of suicide, a specific plan, access to lethal means, and intent to act; this response gathers the information needed to judge imminent risk and decide whether protective measures are needed. Assessing sleep, appetite, and fatigue may clarify depression severity, but it does not reveal whether the client has a plan or access to means. Having the client rate anxiety and depression on a 0-to-10 scale gives a useful symptom baseline, yet it does not elicit suicidal ideation, plan, access, or intent. A urine toxicology screen might add context about substance use, but it is not an urgent safety assessment and does not replace direct questioning about self-harm. When a client expresses hopelessness or a wish to die, the priority is a focused suicide risk assessment.
- A 40-year-old client with depression is developing a safety plan in an outpatient clinic after reporting suicidal thoughts without a current plan. Psychosocial history includes recent eviction notice and limited supports; the client appears anxious and hopeless. The nurse should QUESTION which part of the safety plan?
Answer: "If I start thinking about suicide, I will isolate in my apartment until the feeling passes."
This question tests suicide risk assessment and safety planning. The priority concern is the client's immediate safety with suicidal thoughts, eviction, and anxiety, requiring an effective plan. The nurse should question isolating in the apartment until feelings pass as it increases risk by removing social oversight during vulnerability. Keeping crisis numbers, avoiding being alone by going public, or removing sharp objects and medications are appropriate for enhancing safety. In suicide prevention, safety plans must promote connection and reduce isolation. Avoiding solitary strategies is essential. A transferable strategy is to review safety plans for elements that inadvertently heighten risk, like isolation, and revise accordingly.
